Hernia, Occupational Exposure

x
Risk and prognosis of inguinal hernia in relation to occupational mechanical
exposures – a systematic review of the epidemiologic evidence
Susanne Wulff Svendsen1, Poul Frost2, Marie Vestergaard Vad1,2, Johan Hviid
Andersen1
1
Danish Ramazzini Centre, Department of Occupational Medicine, Regional
Hospital West Jutland

2
Danish Ramazzini Centre, Department of Occupational Medicine, Aarhus
University Hospital
TABLE OF CONTENTS
ABSTRACT..................................................................................................................1
UDVIDET DANSK RESUME (EXTENDED DANISH SUMMARY) ...................3
INTRODUCTION......................................................................................................10
METHODS .................................................................................................................14
Literature search .................................................................................................................................14

Selection of articles ............................................................................................................................14
Article review .....................................................................................................................................15
Grading of evidence for causal and prognostic relations....................................................................15
A note on terminology........................................................................................................................16
RESULTS ...................................................................................................................17
Risk of inguinal hernia by occupation or occupational mechanical exposures...................................19

Risk of inguinal hernia in relation to a single strenuous event ...........................................................35
Postoperative prognosis by occupation or occupational mechanical exposures .................................37
Prognosis with respect to recurrence .............................................................................................37
Prognosis with respect to recurrence and persistent pain..............................................................43
Prognosis with respect to persistent pain .......................................................................................51
Gender differences..............................................................................................................................55
DISCUSSION .............................................................................................................56
Risk of inguinal hernia by occupation or occupational mechanical exposures...................................56

Risk of inguinal hernia in relation to a single strenuous event ...........................................................58
Contributory evidence with respect to risk of hernia formation .........................................................59
Postoperative prognosis by occupation or occupational mechanical exposures .................................61
Gender differences..............................................................................................................................62
Comparison with other reviews of the literature and clinical guidelines............................................63
Evidence synthesis..............................................................................................................................63
Research needs ...................................................................................................................................64
CONCLUDING REMARKS ....................................................................................65
ACKNOWLEDGEMENTS ......................................................................................66
APPENDIX 1 Grading of evidence ..........................................................................67
REFERENCE LIST...................................................................................................69
ABSTRACT
Objective To evaluate the epidemiologic evidence for a causal effect of occupational
mechanical exposures on incidence of inguinal hernia, and for a prognostic effect of
such exposures on hernia recurrence and persistent pain after inguinal hernia repair.
Methods We performed a literature search in Medline, Embase and Web of Science
until November 3 2011 to identify peer-reviewed papers on risk of inguinal hernia or
prognosis after inguinal hernia repair in relation to occupation or occupational
mechanical exposures. We also included studies on risk of inguinal hernia in relation
to single strenuous events. Central information was extracted from included studies,
and strengths and limitations were discussed.
Results All 23 included studies focussed on effects of (work) activities that were
indicators of energy expenditure rather than they reflected specific occupational risk
factors. Eight studies provided information on risk by occupation or occupational
mechanical exposures. Increased risk was reported in six of the eight studies, but the
risk estimates might well be inflated primarily by reporting bias. The negative
findings in two studies might well be explained by bias towards the null due to crude
exposure and/or outcome assessment. Three studies focussed on single strenuous
events, but they primarily reflected patients’ beliefs regarding risk factors.
Information on prognosis with respect to recurrence was found in seven studies. Four
reported an increased risk, but in general, the studies used crude exposure assessment,
and three were also underpowered. Six studies on prognosis with respect to persistent
pain (of which one study also concerned recurrence) were practically non-informative
1
for the purpose of the present review; major drawbacks were probable information
bias, confounding and inadequate reporting of results.
Conclusion There is insufficient epidemiologic evidence (grade 0) to draw
meaningful conclusions about the existence of causal associations between specific
occupational mechanical exposures and the development of inguinal hernia and about
the influence of these exposures on prognosis after inguinal hernia repair with respect
to hernia recurrence and persistent pain. The limited epidemiologic literature does not
rule out important associations.
Key terms
Occupational exposure, inguinal hernia, risk, prognosis
2
UDVIDET DANSK RESUME (EXTENDED DANISH SUMMARY)
Baggrund for problemstillingen
Denne gennemgang blev lavet i henhold til Arbejdsmiljøforskningsfondens opslag i
december 2010 vedrørende udredninger om erhvervssygdomme, tema 2:
Sammenhænge mellem lyskebrok (hernia inguinalis medialis et lateralis) og fysiske
påvirkninger i arbejdslivet.
Lyskebrok
Ved et lyskebrok trænger bughinden og evt. en del af tarmen sig gennem bugvæggen
lige over lyskebåndet. Lyskebrok deles op i det laterale eller indirekte (gennem
lyskekanalen) og det mediale eller direkte (gennem bugvæggen). Lyskekanalen er
skråt forløbende gennem bugens muskulatur og lukkes normalt af en slags klap-
mekanisme. Et medfødt lyskebrok hos drenge er altid et lateralt lyskebrok. Det
laterale lyskebrok udgør ca. 66% af alle lyskebrok hos voksne. Det mediale lyskebrok
presses direkte gennem et svagt sted i lyskekanalens bagvæg og altså ikke gennem
lyskekanalens indre åbning. Medialt lyskebrok ses hos personer med svækket
bugvæg, og med alderen stiger andelen af mediale lyskebrok i forhold til andelen af
laterale. I nogle tilfældene findes medialt og lateralt lyskebrok samtidigt, hvilket
kaldes et saddelbrok. Lyskebrokket kan hos begge køn vise sig som en udbuling i
lysken eller øverst på låret, hos mænd desuden i pungen. Nogle lyskebrok giver så
godt som ingen gener. I mange tilfælde vil der dog være ubehag og smerter, fx ved
fysisk arbejde. Der udføres årligt ca. 10.000 operationer for lyskebrok i Danmark.
Lyskebrok optræder hyppigst hos mænd med en aldersjusteret hyppighed på 7-8
gange i forhold til kvinder.
3
Tunge løft og stående arbejde i længere perioder har været mistænkt som
risikofaktorer for lyskebrok, og enkeltstående fysiske anstrengelser har været
mistænkt for at kunne føre til en pludselig udvikling af et lyskebrok. Sygefravær og
råd om tilbagevenden til arbejdet har sædvanligvis været begrundet med type af
operation og forventede fysiske anstrengelser i arbejdet.
Formål
Det overordnede formål med denne udredning var at belyse, sammenfatte og vurdere
holdepunkterne for eventuelle årsagssammenhænge mellem udvikling af medialt og
lateralt lyskebrok og udsættelse for forskellige mekaniske påvirkninger i arbejdet.
Endvidere var det formålet at undersøge mekaniske påvirkningers betydning for
prognosen (forløbet) efter operation for lyskebrok med hensyn til gendannelse af
brokket og langvarige smerter. Hensigten var at fokusere på arbejde med store
samlede daglige løftemængder, gentagne tunge enkeltløft, personforflytninger og
skub/træk samt langvarigt stående/gående arbejde. Udredningen skulle desuden
omfatte en vurdering af kønnets eventuelle betydning.
Udredningens resultater er samlet i et referencedokument i henhold til retningslinjer
udarbejdet af Arbejdsmiljøforskningsfonden. Udredningen bygger på en gennemgang
af den epidemiologiske litteratur om sammenhænge mellem arbejdsrelaterede
påvirkninger og udvikling af lyskebrok. Hvert studie er gennemgået systematisk, og
der er udarbejdet tabeller for at sikre det nødvendige overblik. Det samlede materiale
er gennemgået for mulige fejlkilder og ensartethed af resultaterne på tværs af de
forskellige studier. Udredningen indeholder herudover afsnit om konkurrerende
4
årsager og mulige årsagsmekanismer. Referencedokumentet afsluttes med en
konklusion i henhold til Arbejdsmiljøforskningsfondens kriterier.
Metoder
Der blev gennemført en litteratursøgning efter videnskabelige artikler i tre
computeriserede databaser: Medline, Embase og Web of Science. Ved søgningen blev
der brugt søgeord relateret til lyskebrok og erhvervseksponeringer (mekaniske
påvirkninger, tunge løft, stående/gående arbejde). Artiklerne skulle være forfattet på
engelsk, skandinavisk, fransk eller tysk samt være fra et tidsskrift med
fagfællebedømmelse. Alle artikler, som blev identificeret ved søgningen, gennemgik
en tretrins screeningsproces: 1) Artiklernes titler blev gennemgået for at finde
undersøgelser, der kunne være relevante, 2) resumeer af muligt relevante artikler blev
læst for at fravælge de undersøgelser, der ikke var relevante, og 3) de resterende
artikler blev læst i deres fulde længde med henblik på at finde dem, der var velegnede
til at indgå i dette dokument. Udvælgelse af artikler blev i første omgang foretaget af
to forskere uafhængigt af hinanden. Den endelige udvælgelse skete efter konsensus i
hele forskergruppen.
Resultater
Ved den indledende litteratursøgning fandtes 1771 artikler, hvor 1625 blev
ekskluderet på baggrund af titel, og 125 blev fravalgt efter læsning af resume eller
læsning af hele artiklen. To relevante artikler blev fundet via andre artikler, og
dermed indgik 23 artikler i referencedokumentet. Sammenhængen mellem
erhvervsmæssige mekaniske belastninger og risikoen for lyskebrok blev belyst i otte
5
artikler, tre artikler omhandlede lyskebrok efter enkeltstående belastninger, og 12
artikler omhandlede prognosen efter operation for lyskebrok.
Af de otte studier af sammenhængen mellem erhvervsmæssige mekaniske
belastninger og udvikling af lyskebrok var tre tværsnitsundersøgelser, fire var case-
kontrol undersøgelser, og et var et prospektivt kohortestudie. Samlet var studierne
behæftet med mange mulige fejlkilder. Det samme gjorde sig gældende vedrørende
enkeltstående belastninger og udviklingen af lyskebrok. Det største problem i
undersøgelserne var målingen af de mekaniske eksponeringer, som i overvejende grad
var baseret på selvrapporterede oplysninger eller stillingsbetegnelser. Andre
problemer hidrørte fra mangelfulde analyser, mangelfuld confounderkontrol, og
undersøgelser baseret på for få personer.
Information om prognose med hensyn til gendannelse af brokket efter operation
fandtes i syv studier. Studiernes kvalitet var ringe i forhold til formålet med denne
udredning. Seks undersøgelser om længerevarende smerter efter lyskebrokoperation
indeholdt stort set ikke informationer, som var anvendelige i forhold til formålet med
denne udredning.
Forskelle mellem mænd og kvinder
De fleste lyskebrokpatienter er mænd, og de fleste undersøgelser vedrører derfor også
mænd. De få undersøgelser, som indbefatter resultater for kvinder, indeholder ikke
resultater, som kan informere om forskel mellem kønnene med hensyn til betydningen
af erhvervsmæssige mekaniske påvirkninger.
6
Konklusion
Der blev gennemført en omfattende litteratursøgning med det formål at udvælge
undersøgelser, som belyste, hvorvidt personer med bestemte erhvervsmæssige
mekaniske påvirkninger har en øget risiko for lyskebrok. På baggrund af i alt 1771
artikler blev 23 udvalgt som egnede og relevante for dette dokument.
Litteraturgennemgangen bygger på studier udført i almenbefolkningen og inden for
forskellige typer af erhverv. I langt de fleste tilfælde har der været tale om
tværsnitsstudier eller case-kontrol studier, hvilket indebærer problemer med at fastslå
den tidsmæssige karakter af eventuelle sammenhænge mellem de mekaniske
eksponeringer og udviklingen af lyskebrok, og risiko for at studierne kan være
behæftet med såvel informations- som selektionsbias. De fleste studier har ikke taget
højde for muligheden for sammenblanding af effekter (confounding). Til vurdering af
erhvervsmæssige mekaniske eksponeringer er der ofte anvendt selvrapporterede,
grove skøn eller fagbetegnelser, og der eksisterer ikke undersøgelser, som har
omfattet kvantitative opgørelser af samlede daglige løftemængder, frekvens af tunge
løft eller daglig varighed af stående/gående arbejde.
Samlet er den epidemiologiske viden om erhvervsmæssige mekaniske påvirkninger
og lyskebrok begrænset. Hvis man inddrager viden fra andre biomedicinske områder,
er der forskning, som peger på mekanismer, der kan kæde mekaniske påvirkninger
sammen med udvikling af lyskebrok. Det drejer sig bl.a. om målinger af trykket i
bughulen, som antages at være en risikofaktor for lyskebrok. Trykket i bughulen er i
eksperimentelle undersøgelser målt højere ved tunge løft, specielt ved løft, som
udføres hurtigt.
7
• Den første konklusion er, at der er utilstrækkelig evidens [0] for en
årsagssammenhæng mellem mekaniske påvirkninger i arbejdet og udviklingen
af lyskebrok.
• Den anden konklusion er, at der er utilstrækkelig evidens [0] for en
årsagssammenhæng mellem enkeltstående påvirkninger i arbejdet og
udviklingen af lyskebrok.
• Den tredje konklusion er, at der er utilstrækkelig evidens [0] for en
årsagssammenhæng mellem mekaniske belastninger i arbejdet og prognosen
for af lyskebrok.
Forskningsbehov
Der er et stort behov for undersøgelser af en højere kvalitet vedrørende
sammenhængen mellem erhvervsmæssige mekaniske påvirkninger og lyskebrok. Det
gælder både bedre eksponeringsoplysninger og mulighederne for at skelne mellem det
laterale og det mediale lyskebrok. Flere af forfatterne til dette referencedokument har
i et samarbejde med Dansk Herniedatabase analyseret risikofaktorer for lyskebrok
baseret på en jobeksponeringsmatrice. Der er endvidere planer om at anvende Den
Muskuloskeletale Forskningsdatabase1 ved Dansk Ramazzini Center til at undersøge
risikofaktorer for lyskebrok. Der er også behov for at undersøge de erhvervsmæssige
forholds betydning for reoperation og smerteforekomst efter operation.
1
Den Muskoloskeletale Forskningsdatabase indeholder data fra ni tidligere danske
epidemiologiske undersøgelser om erhverv og muskelskeletlidelser, som er blevet
samlet med økonomisk støtte fra Arbejdsmiljøforskningsfonden.
8
En arbejdsgruppe bestående af overlæge, ph.d. Susanne Wulff Svendsen,
Arbejdsmedicinsk Klinik, Regionshospitalet Herning, overlæge, ph.d. Poul Frost,
Arbejdsmedicinsk Klinik, Århus Sygehus, stud.med., MMSc Marie Vestergaard Vad
og professor, overlæge, ph.d. Johan Hviid Andersen, Arbejdsmedicinsk Klinik,
Regionshospitalet Herning har skrevet referencedokumentet. Dr.med. Morten Bay-
Nielsen, Gastrokirurgisk afdeling, Hvidovre Hospital, Direktør Nils Fallentin, Center
for Fysisk Ergonomi, Liberty Mutual Research Institute for Safety, Hopkinton,
Massachusetts, USA, og overlæge, dr.med Sigurd Mikkelsen, Arbejds- og
Miljømedicinsk Klinik, Bispebjerg har været eksterne bedømmere.
Bedømmerne har indsendt skriftlige kommentarer til en tidligere version af
dokumentet. Dokumentet blev revideret, og efter et møde d. 8. december 2011 mellem
arbejdsgruppen og bedømmerne, er referencedokumentet færdiggjort.
9
INTRODUCTION
Recently, the Danish Working Environment Research Fund commissioned us to
undertake a systematic review of risk and prognosis of inguinal hernia in relation to
occupational mechanical exposures. The Danish National Board of Industrial Injuries
and the Occupational Diseases Committee requested the review for use in
negotiations on the inclusion of new diseases in the list of occupational diseases and
for adjusting the practice regarding recognition of unlisted diseases caused by the
particular nature of the work. Existing Danish guidelines for recognizing hernias as
unlisted diseases date back to 1997
(https://www.retsinformation.dk/Forms/R0710.aspx?id=84901).
An inguinal hernia is a protrusion of contents of the abdominal cavity through a defect
in the lower abdominal wall above the inguinal ligament (1). Medial (or direct)
hernias penetrate through a non-preformed gap, whereas lateral (or indirect) hernias
pass through the inguinal canal. Lateral hernias may protrude within a patent
processus vaginalis, which is an embryological evagination of the peritoneum. For
both types of inguinal hernia, main symptoms are pain and discomfort due to groin
swelling. The most important complication is incarceration of the hernia, which is a
surgical emergency.
Inguinal hernia is far more common among men than among women, with a reported
age-adjusted male female ratio of 7.5 to 1 (2). Among men aged 25 years and over,
inguinal hernia in terms of a swelling observed at clinical examination or a previous
repair occurred with a lifetime prevalence of 15% (3). The lifetime prevalence
increased with age from 5% in the age group 25-34 years, through 10% in the age
10
group 35-44 years, 18% in the age group 45-54 years, 24% in the age group 55-64
years, and 31% in the age group 65-74 years, to 45% among men aged 75 years and
over (3).
Except in case of serious comorbidity, surgical treatment of symptomatic inguinal
hernias is recommended, whereas watchful waiting may be an acceptable option for
asymptomatic or minimally symptomatic hernias (1;4). According to a register study
from the United Kingdom, the all-ages annual incidence of inguinal hernia repairs
was 13 per 10,000 in the period 1976 to 1986 (5), which probably underestimated the
true incidence because surgery in private hospitals was not included (6). After the first
year of life, the risk of inguinal hernia repair among males rose with age up to age 65
and declined slightly thereafter (5). In male patients aged 15-39 years, 78% of
operated inguinal hernias (excluding pantaloon hernias and hernias with unknown
type) were lateral (7). This percentage was 60% for the age group 40-59 years, and
55% for men aged 60 years or more (7). Around one fourth of all men can expect to
have an inguinal hernia repair at some point in life (2;5), and men account for 90-
95% of all inguinal hernia repairs (5;8;9).
Potential risk factors include a family history of inguinal hernia (10-12), comorbidity
such as prostatic hypertrophy (3) and chronic obstructive pulmonary disease (11),
ethnicity (2), and smoking (1), whereas a high body mass index seems to have a
protective effect (2;3;12;13). Heavy physical workload (14;15) and standing for long
periods at work (http://www.mayoclinic.com/health/inguinal-
hernia/DS00364/DSECTION=risk%2Dfactors) have been implicated as risk factors.
Potentially, a single strenuous event may also induce an inguinal hernia. Although
11
there may be little clinical merit in differentiating between medial and lateral hernias
(1;16), the influence of occupational risk factors may differ.
Several surgical techniques are used that can be broadly categorized as open (sutured
or mesh) or laparoscopic (17). Historically, open techniques were the first to be
applied, whilst laparoscopic techniques did not gain a foothold until after around
1990. Open techniques are most commonly used. Hernia recurrence and persistent
pain are considered the most important adverse outcomes after inguinal hernia repair.
The question is, if generically or quantitatively different occupational mechanical
exposures are related to different probabilities of these outcomes. In Denmark around
the millennium, 17% of all inguinal hernia repairs were performed due to recurrence
(18). The risk of recurrence depends on surgical technique (lower risk after mesh than
non-mesh techniques) (19;20) and maybe also on defective collagen metabolism (21).
Persistent pain for months or even years is a common symptom after inguinal hernia
repair (22-26). In a Danish patient population, pain impairing daily activities was
reported in about 17% one year after open inguinal hernia repair (27) and in 6% after
6.5 years (28). In addition to surgical technique (e.g. laparoscopic techniques seem to
convey a lower risk than open techniques (24;25;29)), surgery for recurrence (24;25),
young age, female gender, preoperative chronic pain, and acute pain in the early
postoperative period have been identified as risk factors (22;30). Psychological
factors may also play a role (30;31).
Another important prognostic outcome is duration of postoperative sickness absence
that has considerable economic implications for society. In part, however, this
outcome reflects advice on convalescence (32) that has traditionally depended on
12
surgery type (open or laparoscopic) and expected physical strain at work (33;34).
Therefore, standardised recommendations on (early) return to work are a prerequisite
for valid comparisons of patient groups with respect to how long time is necessary
before they can resume work after inguinal hernia repair (35). Even when surgeons do
provide standardised recommendations on early return to work, this may not be
followed by the patients, e.g. due to advice to the contrary from general practitioners
or employers. A priori, it therefore seems difficult to extract meaningful information
on prognosis in relation to occupational mechanical exposures from studies that focus
on duration of postoperative sickness absence as an outcome in its own right. In
studies on risk of recurrence and persistent pain, prolonged postoperative sickness
absence may be a protective factor, which should be taken into consideration. These
arguments are reflected in the way we delineated the present review of the literature
on prognosis.
Our overall objective was to produce a systematic review in the form of a reference
document evaluating the epidemiologic evidence for 1) causal relations between
occupational mechanical exposures and the development of lateral and medial
inguinal hernia and 2) effects of occupational mechanical exposures on postoperative
prognosis. Specific objectives were to present exposure-response patterns for
associations that were likely to be causal, and to evaluate the risk of hernia recurrence
and persistent postoperative pain in relation to early return to work characterised by
different mechanical exposures. Part of the objective was to assess any impact of
gender on these relationships. In case of insufficient evidence, a further objective was
to outline major research needs.
13
METHODS
Literature search
We conducted a systematic search in Medline (last updated November 3 2011) using
the terms (inguinal hernia OR hernia repair OR (inguinal hernia AND recurrence) OR
(inguinal hernia AND reoperation) OR (inguinal hernia AND pain)) AND
(convalescence OR work OR occupation OR strenuous OR occupational exposure OR
lifting OR physical load OR standing OR walking OR work related OR occupational
epidemiology OR risk factor*). Corresponding searches were performed in Embase
and Web of Science. Moreover, we searched the reference lists of retrieved original
papers and reviews for additional relevant material. Duplicates were excluded.
Selection of articles
First based on the title and second based on reading of the abstract, two researchers
selected candidate papers to be retrieved in full text. Any differences of opinion were
resolved in consensus. Included papers had to be in English, Scandinavian, French or
German, to be published in a peer-reviewed journal, to describe results of an original
study, and to comprise an analysis of risk or prognosis of inguinal hernia in relation to
occupation or occupational mechanical exposures. In general, we excluded risk
studies that did not include a control group. However, we made an exception from this
criterion with respect to the potential impact of a single strenuous event where we
included case series because we identified no other types of study. Case series that
only considered compensation cases were excluded, and we did not include case
reports. Prognostic studies with duration of sickness absence as the only outcome
were excluded.
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Article review
For each article on risk of inguinal hernia that we finally reviewed, we tabulated a
standardised set of information on study design, population and completeness of
participation, outcome assessment, exposure assessment and exposure contrasts,
effect estimates (with confidence intervals or P-values), and confounder adjustment.
For each article of prognosis with respect to recurrence, we tabulated study design,
population and completeness of participation, type of hernia, surgical technique,
assessment of recurrence, exposure assessment, effect estimates (with confidence
intervals), and outcome probabilities given the exposure in combination with other
predictors. Where counts or prevalence estimates were provided without any effect
estimates, we calculated risk differences or odds ratios with exact 95% confidence
intervals using STATA 11.2.
A brief description of each original study is provided below, together with an
evaluation of the contribution of each study to knowledge. The evaluations are given
in italics. The evaluations were based on a qualitative rating that considered
limitations of design, potential for bias (inflationary or towards the null), adjustment
for potential confounders (in studies of risk), inclusion of relevant potential predictors
in multivariable models (in studies of prognosis), appropriateness of statistical
analyses, and power to detect associations under study.
Grading of evidence for causal and prognostic relations
Across the individual articles on risk of inguinal hernias (or hernia repairs), we rated
the degree of evidence for a causal association between a given exposure and a
defined outcome according to the framework of the Scientific Committee of the
15
Danish Society of Occupational and Environmental Medicine that has been adopted
by the Danish Working Environment Research Fund, appendix 1. We based the rating
on the quality, consistency, and amount of evidence. The evidence for prognostic
relations between occupational mechanical exposures and postoperative outcomes
was evaluated according to the same framework, replacing the word causal with the
word prognostic. We were interested in causal associations between risk factors and
negative prognostic outcomes, rather than prediction per se (36;37). Therefore, we
considered confounding relevant in prognostic studies.
A note on terminology
In the surgical literature on inguinal hernias, the term ‘primary’ is used to designate a
hernia that occurs for the first time or a first-time hernia repair. However, in other
areas of surgical literature, the term ‘primary’ has other connotations: primary
osteoarthritis means osteoarthritis of unknown aetiology as opposed to secondary
osteoarthritis that occurs because of other disorders or trauma. We chose the term
‘first-time’ to designate first-time occurrences.
16
RESULTS
Figure 1 illustrates the literature search. The search revealed 1771 reports, of which
1625 were excluded based on title and 125 were excluded based on abstract or full
text. A total of 23 original papers were included, including one (38) that was
identified through the reference list in one of the other papers (39), and one (40) that
was identified in a review (34). Eleven original papers on risk fell in two groups: eight
that assessed the risk of inguinal hernia in relation to occupation or occupational
mechanical exposures (2;3;11;12;38;39;41;42) and three that assessed the risk of
inguinal hernia in relation to a single strenuous event (43-45). Of twelve original
papers on postoperative prognosis, seven concerned recurrence (35;40;46-50) and six
concerned persistent pain (49;51-55); one study provided results on both outcomes
(49).
17
Figure 1. Flowchart on stages of identification, screening and selection of studies
investigating risk and prognosis of inguinal hernia in relation to occupation or
occupational mechanical exposures.
Potentially relevant studies identified through database searches

Medline: 1609 reports
Embase: 46 reports
Web of Science: 116 reports
1771 reports screened
1750 reports excluded based

on title (n=1625) or
abstract/full text (n=125)
21 full text reports included
1 report included from

reference lists in retrieved
reports and 1 report included
from a review article
11original articles included with information on risk of inguinal hernia in relation to occupation
or occupational mechanical exposures / a single strenuous event
12 original articles included with information on prognosis of inguinal hernia repair (recurrence
or persistent pain) in relation to occupation or occupational mechanical exposures
18
Risk of inguinal hernia by occupation or occupational mechanical exposures
Of the eight epidemiologic studies with information on risk of inguinal hernia in
relation to occupation or occupational mechanical exposures, three were cross-
sectional (3;38;39), four were case-control studies (11;12;41;42), and one was a
prospective cohort study (2). Four studies included only men (3;11;38;39), two
studies included around 80% men (41;42), one study included 40% men (2), and one
study included only women (12). Two studies relied on self-reported outcomes
(38;39), two studies were based on physician diagnoses (2;3) in part reported by the
participants (2), and the four case-control studies focussed on hernia repair
(11;12;41;42). Among the six studies that did not rely on self-reported outcomes, four
studies focussed on inguinal hernias (2;3;11;12), and two studies included femoral
hernias together with inguinal hernias (41;42). Only two studies were explicitly
restricted to first-time inguinal hernias (2;11). Exposure assessment was based on
self-reported work activity levels in four studies (2;3;11;12), a self-reported combined
measure for work and leisure time activity levels in one study (41), job titles in two
studies (38;39), and a job exposure matrix with three (3) or four (42) exposure
categories in two studies. Two studies adjusted for potential confounders (2;3), but
only one study presented adjusted risk estimates (2). The brief descriptions that follow
are arranged first by year of publication, second alphabetically according to the first
author’s surname. In the same order, the eight studies are also presented in table 1.
Abramson et al (3) conducted a cross-sectional population study in Jerusalem. The
study entailed clinical examination of 1883 men aged 25 years and over. The age-
limit was motivated by younger age-groups being absent due to military service.
Participation was 78%. Physical activity at work was assessed by a score based on the
19
reported performance of various activities, the reported frequency of lifting and
carrying, and a three-level job exposure matrix, where the researchers classified all
jobs as light (e.g. bus driver, clerk), active (e.g. postman, carpenter), or heavy (e.g.
boilermaker, dock labourer) (56). In analyses adjusted for age, no significant
associations were found between clinically diagnosed inguinal hernia and physical
activity at work, but this statement was not substantiated by any risk estimates. The
particular strength of this study was that it was based on clinical examination of a
population sample rather than relying on self-reported outcomes or being restricted
to cases diagnosed at a hospital. A further strength was independent exposure
assessment in addition to self-reported estimates. Unfortunately, physical activity at
work was not included in multivariable models, and risk estimates were not presented.
Flich et al (42) compared 128 cases who were surgically treated for inguinal or
femoral hernia in 1986 with 174 controls that were sampled from the recruitment area
of the same hospital. The method used for sampling the controls was not further
described. Exclusion criteria for cases and controls differed in that controls were
excluded if they had a clinical history of any kind of hernia or ‘closely-related
illnesses’. Participation was not described. Descriptive information was provided for
medial and lateral inguinal hernias separately, but all hernia types were combined in
the analyses, possibly also recurrent hernias. Exposure assessment was based on self-
reported information on the job held longest combined with a job exposure matrix
comprising the researchers’ ratings of intensity of physical effort. Possible ratings
were 1) no effort or sedentary work (e.g. night watchman, office worker), 2) light
effort - standing work involving occasional lifting of not too heavy weights (e.g.
waiter, shop assistant, electrician), 3) medium effort - more frequent lifting (e.g.
20
agricultural and construction workers, cleaners (‘house maidens’)), and 4) high effort
- daily effort (e.g. quarry workers, manual warehouse workers). Duration of
employment with these four effort intensities was also investigated. Findings
suggested exposure response relations both for exposure intensity and for exposure
duration, but the results were not adjusted for any confounders. The main strength of
this paper was the independent exposure assessment that minimised any risk of recall
bias. However, the exposure characterization was limited, and no confounder control
was made; the fact that cases and controls did not differ significantly with respect to
mean age does not preclude this source of distortion of the risk estimates. Still, the
risk associated with duration of exposure to physical effort was larger for years of
high effort than for years of light/medium effort, and this difference may not be
explained by age as a confounder.
Mamtani & Cimino (38) compared retired sanitation workers with non-sanitation
workers of whom 38.1% were retired. The study was cross-sectional and comprised
men aged 25 years and over. Only around one third of the sanitation workers
participated. The non-sanitation workers were addressed by a questionnaire that was
sent to each sanitation worker asking him to pass it on to a brother or male first
cousin. Thus, the proportion who participated among invited non-sanitation workers is
unknown. The sanitation workers retired when they were quite young (7.9% were 25-
44 years, 60.2% were 45-64 years), which seems to suggest that they stopped working
because of ill health. The two groups of workers were compared with respect to 17
different illnesses, such as haemorrhoids, diabetes, and tuberculosis. Only one of the
reported ORs was below 1 (the OR for stomach/gastric ulcer, which seems to be
duplicated in the table presenting the results), and nine ORs were significantly larger
21
than 1. Outcome assessment was based on self-report. Among sanitation workers, the
prevalence of inguinal hernia was 8.2% versus 4.7% among non-sanitation workers. It
is not clear whether these percentages represented point or lifetime prevalence. No
specific assessment of mechanical exposures was made, but according to occupational
information on the non-sanitation workers (12.3% were employed in administration
and 14.7% in service jobs), it seems likely that sanitation workers were more exposed
to heavy lifting than non-sanitary workers were. On the other hand, some of the non-
sanitation workers were probably also exposed to heavy lifting (11.4% were
employed in craft and repair). Duration of employment was not considered. Even
though potential confounding factors were not included in the analyses, the two
groups seemed quite comparable. This study had several limitations – low
participation, cross-sectional design, self-reported outcome, weak exposure
characterization, and multiple comparisons. Non-sanitation workers were exposed to
some extent, and this may have led to lower risk estimates than if the comparison
group had been “unexposed”. On the other hand, only retired sanitation workers
were included, whereas two thirds of the comparison group were not retired. Even if
retired sanitation workers had not actually left the labour market, but just their trade,
the restriction to former sanitation workers probably implied selection of unhealthy
workers into this study group. The overrepresentation of a variety of illnesses among
the sanitation workers agrees with the possibility of unhealthy worker selection. Low
participation among sanitation workers may have further exaggerated this source of
bias to the extent that symptomatic workers were more likely to participate. Thus, it
seems likely that inflationary bias explained the increased risk for sanitation workers.
22
Carbonell et al (41) performed a case-control study of 290 cases (79% men) who
underwent inguinal or femoral hernia repair in the period 1987 to 1989, and 290
individually age and sex matched controls who were selected randomly from the
population in the recruitment area of the hospital. The method used for sampling the
controls was not further specified. Exclusion criteria for cases and controls differed in
that controls were excluded if they had previously had surgery for any kind of hernia,
not just the hernia types under study. Participation was not described. It is unclear if
the study was restricted to first-time operations. Descriptive information was provided
for medial and lateral inguinal hernias separately, but all hernia types were combined
in the analyses. Among males, 9.6% (22/228) of the cases had a femoral hernia repair
(the number of males in the case group is misprinted in table 1 of the paper). Among
females, this percentage was 69% (43/62; the numbers of females with different
hernia types are misprinted in table 4 of the paper). Thus, the results for females must
be considered less relevant with respect to risk factors for inguinal hernias. Exposure
assessment was based on an interview with subsequent calculation of an effort score
(1-10) that reflected different aspects of physical activity during work and leisure
time. The calculation of the score was inadequately described, e.g. cut points for
dichotomization of the included variables were not stated. There also seems to be
logical inconsistencies in the construction of the score: physical exertion only at work,
physical exertion only during leisure time, and physical exertion both at work and
during leisure time were all scored 1 for yes and 0 for no, implying that all
participants would be allocated 1 score point for these three items. The score was
calculated for the job held before the appearance of the hernia (it is unclear which
year was chosen for the controls) and for up to three previous jobs, but the number of
cases with information on more than one job was limited. The mean effort score
23
(presumably in the most recent job) was significantly higher among cases than among
controls (5.06 versus 3.21, p<0.001, table 1 in the paper). The effort score was then
divided into four groups, but only one unadjusted OR of 2.92 (95% CI 2.11-4.04,
table 5 in the paper) was reported in relation to the effort needed in the previous job,
so it is unclear which comparison this OR represented. The authors reported an OR
for sex of 0.98 as a result (table 5 in the paper), although this simply reflected the fact
that cases and controls were matched by sex, and for the effort needed for the third
job, the reported OR of 3.22 was classified as insignificant (p=0.71) even though the
95% CI ranged from 1.64 to 6.31. Results were not adjusted for potential
confounders, and the statistical methods disregarded the matching. This study had
many limitations. The statistical analyses were not transparent and did not inspire
confidence. Different outcomes were lumped together. Occupational exposures were
poorly characterized and – most importantly – the effect measures may well be
overestimated due to recall bias (cases may have been more likely to overestimate
their exposures than controls) and confounding.
Liem et al (12) conducted a case-control study among women who underwent
inguinal hernia repair (cases) or surgery for benign skin tumours (controls) at one of
six hospitals between 1994 and 1995. The analyses included 72 cases (participation
89%) of whom 76% underwent first-time inguinal hernia repair and 24% underwent
surgery for a recurrent inguinal hernia, and 125 controls (participation 71%) who
were individually matched to the cases by age and time of surgery. Lateral and medial
hernias were combined in the analyses. Exposure assessment was based on
questionnaire data, and present and past work activity intensities were scored 1-5 and
1-4, respectively. Furthermore, cumulative measures were calculated by multiplying
24
activity score and duration of employment (years); this was done separately for
present and past activity. Selection of variables for inclusion in the final multivariable
conditional regression analysis was guided by univariable unmatched significance
testing of uneven distributions between cases and controls. In this way, occupational
exposure variables were excluded from the final model. A strength of the study was
the sampling frame that probably ensured that the controls were included
independently of occupational exposures and that the controls would have occurred
as cases, had they developed an inguinal hernia. In addition to the relatively large
proportion of recurrent hernias, major limitations were the small study size, and the
method used to select variables for the final model, which meant that the study may
well have overlooked any associations. Based on small numbers, it was noted that
climbing stairs was protective, but this may be an example of reverse causation.
Kang et al (39) reported results from a cross-sectional study of hernias (n= 30,791,
primarily inguinal or unspecified) that employers identified as work-related in a
survey conducted in 1994. The study was restricted to men. No distinction was made
between first-time and recurrent hernias. One-year cumulative incidences were
calculated by industry and occupation categories, and relative risks were presented
using the incidence for the total population of 51,246,000 male workers in private
industries, mines and railways as a reference. The estimates were not adjusted for age
or other factors. The highest relative risks were found in occupations with strenuous,
heavy manual labour. By its focus on inguinal hernias that were judged to be work-
related, this study reflected widespread beliefs regarding risk factors for inguinal
hernias (which was also remarked by the authors) as well as compensation practices
rather than true risks of inguinal hernias across industries and occupation. Thus, the
25
results do not represent valid estimates of the risk of inguinal hernias in relation to
occupational exposures.
Lau et al (11) conducted a case-control study among men aged 18 years or more
(mean age 65 years). A total of 709 cases with a first-time hospital diagnosis of
inguinal hernia were compared with 709 individually age-matched controls, who were
sampled from the hospital’s general surgical clinic and who had not had a hernia
repair previously. The proportion who participated was not stated, and it was not
described why the controls were seen at the clinic. Present work activity intensities
were scored 1-5 by means of a questionnaire. Between cases and controls, a
difference in mean work activity score of 0.1 was observed, and this was found to be
statistically significant. No ORs were presented for the work activity index, which
does not seem to have been considered for multivariable analysis. There were several
limitations. The appropriateness of the control group could not be judged (e.g.
varicose veins may share risk factors with inguinal hernia (3) meaning that inclusion
of patients with varicose veins in the control group would lead to underestimation of
effects), and in particular, there was a potential for inflation of observed associations
due to recall bias and confounding. Even if correct, it must be questioned if the small
difference between cases and controls with respect to the work activity score was
clinically important.
Ruhl & Everhart (2) reported results from a prospective cohort study (NHANES I)
that followed a sample of the US general population who were recruited between
1971 and 1975 when they were 25-74 years old. The study comprised 13,452 persons
(93% of the original cohort), who were followed for a median of 18.2 years. Outcome
26
assessment was based on hospital/nursing home records and interview information
from the participants on hernia diagnoses made by a physician (the last-mentioned
diagnoses were added because hospital/nursing home records were only available for
inpatients). For men, the analyses included baseline interview data on non-
recreational (presumably physical) activity, classified as inactive (11.4% of the men),
moderately active (44.5% of the men), and very active (44.1% of the men). Criteria
for this classification were not stated. For women, the analyses included rural versus
urban residence. It is unclear why urbanicity was not included in the analyses for men,
and why the activity index was not included in the analyses for women. Cox
proportional hazards analyses were performed, but since age-adjusted HRs for activity
level were insignificant for men, this variable was not included in the final model.
Rural residency was significantly related to the outcome among women. This study
benefitted from a longitudinal design, a large sample, a high participation at follow
up, physician-based diagnoses, and consideration of several potential confounders.
However, 44% of the population was classified as having a very active non-
recreational activity level, which suggests that the exposure contrast between
categories was limited. This may have caused underestimation of any association
between a high physical exposure level and the outcome. It may also be questionable
if the activity level at baseline represented the activity level throughout the whole
period. Potentially, rural residence is as a proxy for high physical activity, but this
assumption is not convincing. Hence, for the purpose of the present review, the
exposure assessment was weak and exposure misclassification could easily have
biased estimates of associations towards the null.
27
Table 1. Main characteristics of eight epidemiologic studies on risk of inguinal hernia by occupation or occupational mechanical exposures. The
studies are ordered first by publication year and second alphabetically according to the first author’s surname.
Study Design and Outcome Exposure Measure of risk, point estimate, Confounders
population 95% CI or p-value considered
Abramson et Cross-sectional Clinical A score based on self- No significant relations were Adjustment for age
al 1978 (3); population study, examination: a) reported performance found between the measures of
Israel men only, age 25+ obvious hernias – of various activities physical activity at work and the Distributions of various
years, n=1883, groin swellings outcomes, but results were not risk factors across
participation 78% and repaired Self-reported lifting or shown effort categories were
hernias, b) carrying not shown
palpable impulse
only A job exposure matrix Multivariable analyses
with three activity did not include physical
levels based on the activity at work
researchers’
judgement
Flich et al Case-control study, No specification Estimates of physical Unadjusted analyses

Effort OR 95% CI
1992 (42); both men and regarding first- effort were allocated
No/light 1 -
Spain women, mean age time surgery and to each participant Medium 1.84 0.95- 3.69 Descriptive data was
50-51 years surgery for using a job exposure High 6.39 2.66-15.57 provided on age, sex,
recurrence matrix with four [Our calculations based on table 5 in the weight, height,
Cases, n=128, activity levels based paper] smoking, and alcohol
83.6% men, Cases were on the researchers’ consumption among
participation treated for judgement combined cases and controls
unspecified inguinal or with self-reported
femoral hernias in information on job
28
Controls, n=174, a surgical hospital held longest Distributions of these

86.8% men, department in factors across effort
enrolled from the 1986 Years of light/medium 0 years 1.0 categories were not
recruitment area of effort 1-19 years 4.0 shown
the hospital, Hernias were 20-39 years 7.9
participation distributed with 40-69 years 11.4
unspecified 57.8% lateral
26.6% medial p≤0.001
7.8% pantaloon
(i.e. combined Years of high effort 0 years 1.0
medial and 1-19 years 13.6
lateral) 20-39 years 65.0
7.8% femoral
P≤0.05
Mamtani & Cross-sectional, Self-reported Comparison of job OR 1.79 (1.24-2.58) Unadjusted analyses
Cimino 1992 men only, age 25+ inguinal hernia titles
(38); United The study was
States Sanitation workers Prevalence 8.2% restricted to men. The
retired after 1971 two groups were
and alive in 1986, similar with respect to
n=1933, age, weight, alcohol
participation 35.1% consumption, current
smoking, and probably
Non-sanitation Prevalence 4.7% also ethnicity and
workers (brothers socioeconomic status
and male first
29
cousins of the
sanitation workers),
predominantly blue
collar workers –
38.1% were retired,
n=801,
participation
unknown
Carbonell et Case-control study, No specification Self-reported physical Effort OR 95% CI Unadjusted analyses
al 1993 (41); both men and regarding first- effort during work and 0-<2.5 1 -
2.5-<5 1.2 0.7-2.2
Spain women, mean age time surgery and leisure time (a score, Descriptive data was
5-<7.5 3.2 1.9-5.4
59 years (range 21- surgery for 1-10, divided into four 7.5-10 3.5 0.8-17.4 provided on education
90); cases and recurrence categories) [Our calculations based on table 2 in the level, income, height
controls were paper that only allowed unconditional and weight, coffee and
individually Cases underwent analyses. Thus, we treated the data as if alcohol consumption,
matched by age and inguinal or cases and controls were frequency smoking, chronic
matched]
sex femoral hernia cough, frequency of
repair from 1987 defaecation and
Cases, n=290, 79% to 1989 consistency of faeces
men, participation
unspecified Distributions of these
factors across effort
Controls, n=290, categories were not
from the shown
background
population, 79%
30
men, participation
unspecified
Liem et al Case-control study, First-time Median work activity score Unadjusted analyses
1997 (12); women only, age inguinal hernia with respect to work
The 20-80 years, cases repair, n=55 Self-reported present Present physical work
Netherlands and controls were (76%), or surgery physical work activity Cases 2.9 Descriptive data were
individually for recurrence, (a score, 1-5) Controls 2.9 provided on age,
matched by age and n=17 (24%), from p=0.6 (Mann-Whitney U-test) socioeconomic status,
date of surgery 1994 to 1995 marital status, body
Self-reported work Past physical work mass index, smoking,
Cases, n=72, Hernias were activity in the past Cases 1 abdominal operations,
participation 81% distributed with (sedentary, score 1; Controls 2 pregnancies,
54% lateral standing, score 2; p=0.9 (Mann-Whitney U-test) constipation,
Controls, n=129, 42% medial labour, score 3; heavy obstructive pulmonary
who had excision of 4% unclassified labour, score 4) disease, obstructive
benign tumours of urinary tract disease,
the skin, trauma, family history
participation 73%, of inguinal hernia
(4 controls did not
match a case and Distributions of these
were excluded) factors across effort
categories were not
shown
Kang et al Cross-sectional, Primarily inguinal 9 industries Several risk estimates were Unadjusted analyses
1999 (39); men only or unspecified presented as compared to the
31
United States A nationwide study hernias, both 17 broad groups of overall annual incidence. The top
representing first-time and occupations five high-risk occupations among
51,246,000 male recurrent, 40 major occupations were:
workers n= 30,791, 40 major occupations
resulting in at Non-construction labourers
least one day RR 4.5 (95% CI 4.0-5.0)
away from work,
corresponding to Miscellaneous machine operators
an overall annual RR 2.8 (95% CI 2.4-3.3)
incidence rate of
6.0 per 10,000 Plumbers and pipefitters
male workers RR 2.7 (95% CI 2.2-3.2)
The hernias were Construction labourers

identified in a RR 2.3 (95% CI 1.9-2.7)
survey in 1994,
asking the Freight, stock, and material
employers to handlers
report work- RR 2.2 (95% CI 1.9-2.6)
related cases
Lau et al Case-control study, First-time Self-reported present Comparison of mean work Unadjusted analyses
2007 (11); men only, mean age hospital diagnosis physical work activity activity scores with respect to work
Hong Kong 65 years, cases and of inguinal hernia (a score, 1-5)
controls were Cases: 2.8 (SD 0.5) Separate analyses were
individually Among cases who Controls: 2.7 (SD 0.5) performed for smoking,
matched by age had surgery p=0.03 (Student t-test) chronic obstructive
32
Cases, n=709, (n=554), hernias Self-reported total In subanalyses, the total activity pulmonary disease,
participation were distributed activity index (work, index was associated with medial other specified
unspecified with sport and leisure time) as well as lateral hernias diseases, a family
history of hernia,
Controls, n=709, 62% lateral chronic cough,
sampled from the 30% medial constipation, use of
general surgical 8% combined laxatives
clinic, participation
unspecified
Ruhl & Prospective cohort First-time Self-reported non- Effort HR* 95% CI Analyses were
Everhart study, both men physician recreational physical Low 1 - stratified by sex and
Moderate 1.3 0.92-1.9
2007 (2); (40%) and women diagnoses of activity (men) adjusted for age
High 1.3 0.90-1.8
United States (60%) inguinal hernia * Age-adjusted
recorded in Smoking, alcohol
A national sample connection with Urban: HR 1.0 consumption, body
Rural versus urban
of the general US overnight medical Rural: HR 1.8 (95% CI 1.3-1.6) mass index, ethnicity,
residence (women)
population facility stays Adjusted for age, height, chronic cough, education, recreational
established 1971- (60%) or first- and umbilical hernia physical activity, hiatal
1975 time physician or umbilical hernias,
diagnoses of chronic cough, chronic
5316 men and 8136 inguinal hernia bronchitis/emphysema,
women (93% of the reported by the constipation, and bowel
original cohort) participants movement frequency
were followed up (40%) were considered
with a median
follow-up period of 500 cases Factors related to
33
18.2 years occurred among inguinal hernia in age-

men and 120 adjusted models were
among women evaluated in
multivariable analyses
____________________________________________________________________________________________________________________
34
Risk of inguinal hernia in relation to a single strenuous event
The risk of inguinal hernia in relation to a single strenuous event was addressed in
three case series that included a total of 582 surgical patients (43-45). Two studies
were not restricted to first-time inguinal hernia, but included recurrent hernias (43;45)
and other types of hernia (43). The proportion of patients who reported a sudden onset
ranged from 7% and 11% to 43%, and patients with a sudden onset tended to relate
their hernia to a specific strenuous event.
Smith et al (1996; United Kingdom) (45) reported results from a series of 129
patients (95% men) who were seen at a surgical department due to first-time or
recurrent inguinal hernia over a six-month period (calendar year not specified). It is
unclear if the data was collected by interview or questionnaire. Participation was not
stated. None of the patients were engaged in claims for industrial injury
compensation, but it is unclear whether this was an exclusion criterion. A sudden
onset was reported by 7% of the patients (n=9), all of whom had a first-time hernia.
Eight patients thought that their hernias were related to lifting strains at home or at
work, and one patient remembered a fall. The sudden onset hernias were medial in
five cases, lateral in three cases and unknown in one case, but for the gradual onset
group, the numbers with lateral and medial hernias were not reported. The study
reflected beliefs regarding risk factors for hernias, rather than evaluating if anything
unusual actually took place shortly before the onset.
Pathak & Poston (2006; United Kingdom) (43) reported questionnaire-based results
from a series of 133 patients with 135 inguinal (85%) or other abdominal hernias
(15%), of which 19% were recurrent. The patients were seen at a general surgical
35
hospital clinic over a six-month period in 2003. Participation was 99%, the male
female ratio was not reported. A sudden onset was reported by 11% of the patients
(n=14), who thought that their hernia was caused by a single strenuous or traumatic
event in terms of heavy lifting at work (n=1), strenuous exercise and stretching (n=3),
coughing (n=2), or an unidentified activity (n=8). No distinction was made between
medial and lateral hernias. The study reflected beliefs regarding risk factors for
hernias, rather than evaluating if anything unusual took place shortly before the
onset.
Sanjay & Woodward (2007; United Kingdom) (44) reported questionnaire-based
results from a series of 320 patients who underwent inguinal hernia repair between
1995 and 2004. Only first-time hernias were included. Participation was 62%
(320/520), the male female ratio was not reported. A sudden onset was reported by
43% (n=137). Lateral hernias were diagnosed in 74% of the patients with a sudden
onset and in 57% of patients with a gradual onset (p<0.05). Heavy work was reported
by 31% (42/137) in the group with a sudden onset and by 9% (14/163) in the group
with a gradual onset (for heavy and manual work combined, the corresponding
percentages were 46% and 17%, p<0.05). Patients with a sudden onset thought that
their hernia was caused by a single strenuous or traumatic event in terms of one of
four pre-specified response options: lifting (n=93), coughing (n=20), exercise (n=14),
and gardening (n=10). The study reflected beliefs regarding risk factors for inguinal
hernias, rather than relations to unusual events that took place shortly before the
onset. The long recall period of up to nine years and the pre-specified response
options probably increased the risk that patients rationalized after the fact. The
hernia may also have been present, but unnoticed by the patient before an event that
36
provoked symptoms (57). However, these sources of error could not explain the
finding that lateral hernias were more likely to have a sudden onset than medial
hernias were, nor the increased occurrence of a sudden onset among patients with
heavy work. If corroborated, these observations might suggest an injury mechanism
where increased intraabdominal pressure makes the hernia protrude preferentially
through the preformed canal.
Postoperative prognosis by occupation or occupational mechanical exposures
Of the twelve studies on prognosis, one study concerned patients treated
laparoscopically (40), and three studies concerned patients who were treated either
laparoscopically or by open surgery (49-51) – two of these studies presented results
from the same trial (50;51). The remainder of the studies concerned patients who had
open surgery (as judged from publication year, if not stated explicitly). Duration of
postoperative sickness absence was considered in seven studies (35;46-48;50;51;53),
but was not described in relation to occupational exposures in two of the studies
(50;51). In three studies, part of the patients received standardised advise on short
convalescence (35;46;48). The brief descriptions that follow are arranged first
according to prognostic outcome (recurrence or persistent pain), second by year of
publication, and third alphabetically according to the first author’s surname. The
seven studies on recurrence are also presented in table 2.
Prognosis with respect to recurrence
Ross (47) conducted a four-year follow up study of hernia recurrence among 260
adult male patients who underwent surgery for first-time or recurrent inguinal hernia.
As judged from the publication year (1975), the study concerned open repair.
37
According to self-report, a total of 22 hernias (8.5%) recurred. No statistical analyses
were performed. Results were presented by means of a figure showing the distribution
of patients and recurrences according to number of weeks off work and occupational
exposures classified as light work (e.g. office work), medium work (e.g. shop keepers,
sales representatives), or heavy work (labourers, welders, butchers). Based on our
readings from the figure, the median time until return to work was 5, 6, and 8 full
weeks in the three exposure categories, respectively, and 75.7% (84/111), 52.6%
(50/95), and 20.4% (11/54) of the patients in the three exposure categories had
returned to work after 6 full weeks. Among patients with light work who returned to
work before 6 full weeks, 4.8% had a recurrence, and among patients with light work
who returned to work after 6 full weeks, 3.7% (1/27) had a recurrence. Among
patients with medium or heavy work who returned to work before 6 full weeks, 11.5%
(7/61) had a recurrence, and among patients with medium or heavy work who
returned to work after 6 full weeks, 11.4% (10/88) had a recurrence. As stated by the
author, early return to work (which we have interpreted as return to work before 6 full
weeks after surgery) did not seem to increase the risk of hernia recurrence, and this
applied whether the patients returned to light, medium, or heavy work. However, our
readings and calculations showed that medium and heavy work was associated with a
risk of recurrence of 11.4% (17/149) against 4.5% (5/111) for light work, yielding a
univariable risk difference of 6.9% (95% CI 0.51%-13.3%, our calculation; the
calculation was based on the assumption that all patients had the same follow up time
– if recurrences occurred earlier in the exposed group, this assumption would lead to a
conservative estimate of the risk ratio). The study was observational, and patients may
have adjusted their convalescence so that symptoms and workload were balanced in a
way that minimised the risk of recurrence. Results may not be generalizable to
38
situations where all patients are expected to return to work early. Medium and heavy
work was associated with an increased risk of recurrence irrespective of time off
work, which suggests that prolonged convalescence did not sufficiently protect
against the increased risk.
Bourke et al (46) reported results of a randomised controlled trial comparing an
intervention group who were advised to return to full activity as early as possible and
a control group who received usual advice on convalescence. Male patients were
enrolled in the study two to three weeks after an inguinal hernia repair that was
performed between 1976 and 1981. As judged from the publication year, the study
concerned open repair. After one year, 491 patients (95%) were followed up. In the
intervention group 3.3% (8/246) had a recurrence as compared to 4.1% (10/245) in the
control group; this difference was not significant. The intervention shortened the
median convalescence from 65 to 48 days in comparisons restricted to workers
(n=369). In the intervention group, patients with light (no lifting), intermediate (light
lifting), and heavy work (heavy lifting) returned to work after a median of 42, 50, and
51 days, respectively. Among patients with heavy work, 3.5% (3/85) had a recurrence
in the intervention group versus 1.1% (1/95) in the control group, and the
corresponding univariable risk difference was 2.5% (95% CI -2.0%-6.9%; our
calculation). Overall, shorter convalescence was not significantly related to an
increased risk of recurrence. Due to small numbers, it was not possible evaluate if
earlier return to work was associated with a higher probability of recurrence among
patients with heavy work.
39
Taylor & Dewar (48) conducted two randomised controlled trials from 1978 to 1980
focussing on hernia recurrence in relation to duration of sickness absence and type of
work. One trial comprised 96 presumably male naval and marine officers (mean age
30 years, range 17-54 years, participation 100%) who were ordered to resume full
duties either 3 weeks or 3 months after an uncomplicated open inguinal hernia repair
(the study received ethical approval, but it seems that the officers were not asked for
consent to participate). The other trial comprised 119 male civilians (mean age 47
years, range 18-60 years, participation 91%) with unspecified jobs who underwent the
same type of surgery and who were either advised to resume work after 3 weeks or
received usual advice. In both trials, the patients’ type of work was classified as
heavy, light, or sedentary. Among the officers, 34% had heavy work, 49% had light
work, and 17% had sedentary work. Among the civilians these percentages were 28%,
25%, and 47%. Recurrence within one year did not differ, but only two recurrences
were observed altogether (both occurred among naval and marine officers who
returned to full duties after 3 months). The trials were underpowered to detect
differences between the intervention and control groups with respect to recurrence.
Le et al (40) conducted a follow-up study of 196 patients (98% men, mean age at
follow-up 51 years, range 20-86 years). They were clinically examined on average 34
months (range 20-42 months) after laparoscopic repair of a first-time (89%) or
recurrent (10%) inguinal hernia, or a femoral hernia (1%). Surgery was performed
between 1996 and 1997. At follow-up, information was collected on “sustained
physical activity”; it is not clear whether this information could be retrieved from
clinical files or was obtained by a retrospective interview. No distinction was made
between physical activity at work or during leisure time, and the timing of the
40
physical activity in relation to surgery was not specified. The duration of
postoperative sickness absence was not described. Among patients with sustained
physical activity, 30.3% (10/33) had a recurrence, whereas among patients without
such activity, the percentage was 14.7% (24/163). Thus, the univariable risk
difference was 15.6% (95% CI -1.0%-32.2%; our calculation assuming that all
patients had the same follow up time, see above). Among patients with a recurrent
hernia, 68% (23/34) were asymptomatic; this percentage was not specified according
to physical activity. Multivariable analyses were not performed. Results suggested
that sustained physical activity is a risk factor for recurrence after laparoscopic
hernia repair. However, recall bias may have inflated the risk difference, and the
result is difficult to interpret because of the unspecified timing and character of the
physical activity.
Bay-Nielsen et al (35) advised 1059 men who underwent elective, open repair (with
mesh) of a first-time inguinal hernia to return to work and daily activities on the day
after surgery (participation 98% (1059/1084)). Among the 1059 men, 646 were
employed or self-employed. In a preoperative questionnaire, they classified their
occupational physical activities as “sedentary work” (22%), “walking, no heavy
lifting” (28%), “intermittently strenuous work” (33%), or “constantly strenuous work”
(14%). For the remainder, occupational physical activities were unspecified (5%). The
median time off work ranged from 4.5 days to 14 days for patients in the lowest and
highest occupational exposure categories, respectively. One month after surgery, 25%
of the patients with constantly strenuous work were still sick-listed as compared with
10% of the patients with sedentary or walking work with no heavy lifting. Pain and
wound problems were reported as the most common reasons for delayed resumption
41
of work. All 1059 men who received advice on resuming work early were compared
with 1306 eligible patients who had surgery in the participating departments, but were
not included in the study for administrative reasons, and with 8297 comparable
patients who had surgery in other departments. The two comparison groups were not
characterized with respect to age, physical strain at work, or time off work after
surgery. Within up to two years of follow up (median follow-up time 16-17 months),
reoperation rates (as a proxy for recurrence) did not differ between the three groups of
patients. Reoperation rates were calculated as Kaplan-Meier estimates and compared
with the log-rank test. The study indicated that patients with physically strenuous
work had a longer period of convalescence after inguinal hernia repair than patients
whose work was not strenuous, even though standardised advice on early return to
work was given. While in general reassuring with respect to hernia recurrence in
relation to early return to work among patients treated by an open repair technique,
the most highly exposed group was small, the comparisons across groups were not
stratified by exposure category, and the longer periods off work among patients with
physically strenuous work may have had a protective effect. Hence, the study may
have overlooked an increased reoperation rate among patients with constantly
strenuous work.
Arvidsson et al (50) reported results of a randomised trial comparing two surgical
techniques (laparoscopic repair versus open repair without mesh). From 1993 to 1996,
1068 male patients aged 30 to 70 years were enrolled in the trial in connection with
first-time surgery for unilateral inguinal hernia. A total of 920 (86%) patients were
followed up by an independent observer after five years or had developed a recurrence
during follow-up. Recurrence was defined as a bulge in the operated groin when
42
standing and straining or as a positive herniography. At baseline, patients were
categorized as occupied in a job with light (39%), moderate (20%), or heavy physical
exposures (23%), or as unoccupied (4%), retired (12%), or having an unspecified
occupational status (1%). Median sick-leave was 11 and 12 days in the two surgery
groups, respectively. Duration of sick-leave was not described in relation to
occupational physical exposures. In a nonlinear mixed model analysis, occupational
exposure status was not a prognostic variable for recurrence after either type of
surgery (it is unclear if the analysis was uni- or multivariable). The result was
reassuring, but exposure assessment was crude, which may have masked negative
effects of specific exposures. To the extent that patients with heavy exposures had
longer sick-leave, a protective effect of sick-leave would also tend to obscure any
negative impact of occupational exposures on prognosis.
Prognosis with respect to recurrence and persistent pain
Matthews et al (49) followed 1696 men (participation 86% (1696/1983)) for a
minimum of two years after open (n=834) or laparoscopic (n=862) repair of a first-
time or recurrent inguinal hernia. Information on physical activity level was collected
by a preoperative questionnaire. Recurrences were identified by clinical examination
or ultrasonography performed by an independent observer at follow-up appointments
two weeks, three months, one year, and two years after surgery, or at the time of a
reoperation. A higher preoperative activity level (‘active’ versus ‘sedentary’) during
work or leisure-time predicted a higher risk of reoperation after a laparoscopic repair
(adjusted OR 1.89, 95% CI 1.41-2.51; we calculated this result taking exp(x) of the
values for beta and confidence limits reported in table 6 of the paper). Physical
activity level did not predict reoperation after open repair. Patients who reported that
43
their highest physical activity level during work or leisure-time was moderate, heavy
or very heavy had a lower risk of pain exceeding three months after a laparoscopic
repair than patients who reported their activity level to be light (adjusted OR 0.52;
95% CI 0.30-0.89). Physical activity level did not predict long-term pain after open
repair. Duration of postoperative sickness absence was not taken into account. This
study benefitted from prospective data collection and from separation of the two
surgical procedures and the two postoperative outcomes. Results suggested that a
higher than light activity level could be associated with a higher risk of reoperation,
but a lower risk of persistent pain after a laparoscopic repair. Physical activity level
did not predict reoperation or long-term pain after open repair. However, the crude
assessment of physical activity levels was a weak point.
44
Table 2. Main characteristics of six epidemiologic studies on prognosis with respect to recurrence after inguinal hernia repair by occupation or
occupational mechanical exposures. The studies are ordered first by publication year and second alphabetically according to the first author’s
surname.
Study Design and population Type of hernia, Exposure and – if Measure of risk, point Other predictors
surgical technique, applicable - estimate, 95% CI considered
and definition of intervention to
recurrence shorten convalescence
Ross 1975 A four-year follow-up First-time or Light work Risk of recurrence: Duration of
(47); study of 260 adult men, recurrent inguinal Medium work Light work 4.5% convalescence
United participation not stated hernia, open repair, Heavy work Medium/heavy work 11.4%
Kingdom calendar year(s) of
surgery not stated Exposure assessment Risk difference:
according to 6.9% (0.51%-13.3%)
Recurrence according researcher’s judgement
to self-report Risk of recurrence according
to exposure and duration of
convalescence:
Light work
< 6 full weeks 4.8%
≥ 6 full weeks 3.7%
Medium/heavy work
< 6 full weeks 11.5%
≥ 6 full weeks 11.4%
[Our calculations based on readings

from the figure in the paper]
45
Bourke et A randomised controlled Unilateral inguinal Light work Risk of recurrence: Duration of
al 1981 study comprising 491 hernias, no Intermediate work All types of work convalescence
(46); men, of whom 369 were specification Heavy work Intervention group 3.3%
United workers, age not regarding first-time Control group 4.1%
Kingdom specified, participation surgery and surgery Exposure assessment
95% for recurrence, open according to Heavy work
repair, 1976-1981 researchers’ judgement Intervention group 3.5%
Follow up after one year Control group 1.1%
Recurrences were Advice on early return
identified by clinical to full activity versus Risk difference in the group
examination and usual advice with heavy work:
defined in terms of 2.5% (-2.0%-6.9%)
need for reoperation [Our calculation]
or a truss
Taylor & Two randomised Unilateral inguinal Naval and marine Only two recurrences Duration of
Dewar controlled studies hernias, no officers: occurred, both among convalescence
1983 (48); specification naval/marine officers with long
United 1) Naval marine officers, regarding first-time 34% had heavy work, convalescence
Kingdom n=96, mean age 30 years, surgery and surgery 49% light work, and
participation 100% for recurrence of 17% sedentary work
inguinal hernia, open
repair (without Ordered to resume full
mesh), 1978-1980 activities after 3 weeks
versus after 3 months
46
2) Male civilians, who Recurrences were Civilians:

had a job, n=119, mean identified by clinical
age 47 years, examination and 28% had heavy work,
participation 91% defined in terms of 25% light work, and
need for reoperation 47% sedentary work
or a truss
Advice to resume full
activities after three
weeks versus usual
advice
Both officers and

civilians:
Exposure assessment
according to
researchers’ judgement
Le et al A follow-up study of 196 First-time (89%) or Sustained physical Risk of recurrence: None
2001 (40); patients (98% men), recurrent (10%) activity at work or Exposed 30.3%
France mean follow-up time 34 inguinal hernia or during leisure time Non-exposed 14.7%
months, mean age at femoral hernia (1%), according to interview
follow up 51 years, laparoscopic repair, or maybe clinical files
participation not stated 1996-1997
47
Recurrences were Risk difference:

identified by clinical 15.6% (-1.0%-32.2%)
examination [Our calculation assuming that all
patients had the same follow up time]
Bay- A prospective follow-up First-time inguinal Constantly strenuous Risk of recurrence was not Return to most
Nielsen et study of an intervention hernia, open repair work stated according to exposure or strenuous leisure
al 2004 group that comprised (with mesh) Intermittently strenuous duration of convalescence activity (separate
(35); 1059 adult men work (only duration of analyses)
Denmark (participation 97.7%). Reoperation was used Walking, no heavy convalescence was stated
They were followed for as a proxy for lifting according to exposure)
up to 24 months after recurrence Sedentary work
surgery (median 16
months) Exposures were
assessed by self-report
Two comparison groups At the median follow up time,
a) 1306 men from the Advice to return to the reoperation rates in the
same hospital department work and daily intervention group and in the
(median follow-up time activities on the day two comparison groups were
17 months), b) 8297 men after surgery 0.7, 1.6, and 1.4, respectively.
from different hospital (intervention group) Employment status was not
departments (median versus usual advice (the considered
follow-up time 16 two comparison
months) groups)
48
Arvidsson A randomised controlled First-time inguinal Light physical work Occupational physical American
et al 2005 study comparing two hernia treated by Moderate physical exposures were not associated Association of
(50); surgical techniques laparoscopic (n= 454) work with recurrence after Anaesthesiology
Sweden or open (without Heavy physical work laparoscopic or open (without grade, age,
920 men with five years mesh) repair (n=466) Unoccupied mesh) repair smoking, hernia
of follow-up or Retired size, operating
development of a Recurrence was (It is unclear if this was based time, com-
recurrence during the defined as a bulge in (It is unclear if the on uni- or multivariable plications, sick
study period the operated groin exposures were analysis) leave, and
when standing and classified by the complaints at
straining or a positive patients or by the three months
herniography researchers)
Matthews A randomised controlled First-time or Activity level during Laparoscopic repair: The model
et al 2007 study comparing two recurrent inguinal work or leisure time included BMI,
(49); surgical techniques hernia treated by Active versus OR 1.89 (1.41-2.51) surgeon
United laparoscopic (n=862) sedentary experience, and
States 1696 men with at least or open (with mesh) Open repair: American
two years of follow-up repair (n=834) (It is unclear if the Association of
(participation 86%) exposures were Activity level not included in Anaesthesiology
Recurrence identified classified by the final model grade
by clinical patients or by the
examination, researchers) Several other
ultrasonography, or demographic,
reoperation comorbid, hernia
49
and surgical
factors were
considered
____________________________________________________________________________________________________________________
50
Prognosis with respect to persistent pain
Salcedo-Wasicek & Thirlby (1995; United States) (53) conducted a follow up study
of 44 male patients with a mean age of 46 years who underwent first-time inguinal
hernia repair in 1992, using an open technique (the study is not a matched case-
control study, although the authors stated so; all participants underwent inguinal
hernia surgery). The outcomes were number of days to pain-free status and number of
days until return to work according to a telephone interview. The number of days off
work was higher among patients with workers’ compensation than among patients
with a commercial insurance. Standardised advice on early return to work was not
given. Both type of insurance coverage (workers’ compensation versus a commercial
insurance) and self-reported work level (sedentary, moderate, or heavy lifting) were
among the variables that were included in a multivariable Cox proportional hazards
regression analysis. Type of insurance coverage was reported as the only significant
prognostic factor with respect to duration of pain. However, type of insurance
coverage and work level correlated. Among patients with a workers’ compensation,
4% had sedentary work, 32% had a moderate work level, and 64% performed heavy
lifting. Among patients with a commercial insurance the corresponding percentages
were 64%, 18% and 18%. Unadjusted, partly adjusted, and fully adjusted HRs were
not reported. Incidentally, the percentage with lateral hernias was 73% among patients
with a workers’ compensation against 55% among patients with a commercial
insurance. It is a challenge to interpret results of multivariable analyses that include
highly correlated variables, and the study could not disentangle effects of workers’
compensation and heavy work. The results may suggest that preoperative heavy work
was associated with postoperative pain. Alternatively, the results may suggest that
attempts to return to heavy work aggravated or perpetuated postoperative pain, or
51
that the patients omitted early return to work because they expected aggravated
symptoms or hernia recurrence. Therefore, the study is hardly informative for the
purpose of the present review.
Poobalan et al (2001; United Kingdom) (55) conducted a follow-up study among 226
patients (participation 64%, mean age 61 years, unspecified gender distribution) who
had undergone open surgery (with or without mesh) for first-time or recurrent
inguinal hernias between 1995 and 1997, i.e. 21 to 57 months previously. They were
asked to recall pain lasting more than three months after the operation, and to state
their employment status; it is not clear whether this meant their present employment
status or their employment status at the time of surgery. Type of work was not
specified. Patients who were working (full or part time) had a 35% (35/101) risk of
pain against a risk of 14% (14/97) for those who had retired. Thus, the univariable risk
difference was 20% (98% CI 8.6%-31.8%; our calculation based on table 1, assuming
that all patients had the same follow up time, see above). The comparison was not
adjusted for any potential confounders, and duration of postoperative sickness absence
was not taken into account. Increasing age was associated with less chronic pain. Risk
associated with employment status without any indication of occupational exposures
is difficult to interpret, and age probably confounded the comparison. Therefore, the
study is hardly informative for the purpose of the present review.
Nienhuijs et al (2005; the Netherlands) (52) conducted a prognostic study based on a
randomised trial that compared three types of open hernia repair (with mesh). From
2001 to 2003, 334 patients (97% men (58)) were enrolled in the trial and 96% were
followed up after a median of 15.4 months. For patients who were employed versus
52
patients who were not employed, the univariable risk difference for persistent pain at
follow up was 12.3% (95% CI 1.4%-23.2%; our calculation based on data in table 2
of the paper, assuming that all patients had the same follow up time, see above): 48%
(90/186) of the employed and 36% (48/133) of the unemployed patients had persistent
pain. Duration of postoperative sickness absence was not taken into account. Age was
the only predictor that remained significant in a multivariable analysis that also
included body mass index, hernia characteristics, surgeon experience, operating time,
and type of anaesthesia. With increasing age, less chronic pain was reported, and the
majority of the elderly were unemployed. The study did not consider type of
employment, and the multivariable analysis suggested that age explained the
association between employment and persistent pain.
Berndsen et al (2007; Sweden) (51) reported results of a randomised trial comparing
two surgical techniques (laparoscopic repair versus open repair without mesh);
Arvidsson et al (2005) (50) reported results of the same trial with respect to
recurrence, see above. From 1993 to 1996, 1068 male patients aged 30 to 70 years
were enrolled in the trial when they had first-time surgery for unilateral inguinal
hernia. After five years, 867 (81%) were followed up by an independent observer with
respect to “discomfort”; patients were excluded in case of hernia recurrence. At
baseline, patients were categorized as occupied in a job with slight (39%), moderate
(21%), or heavy exposures (23%), or as unoccupied (4%), retired (12%), or having an
unspecified occupational status (1%). Median sick-leave was 10 and 14 days in the
two surgery groups, respectively. Duration of sick-leave was not described in relation
to occupational exposure status. In univariable logistic regression analysis,
occupational exposure status was not a prognostic variable for long-term discomfort
53
for either type of surgery; multivariable analyses were not conducted. The result was
reassuring, but exposure assessment was crude, which may have masked negative
effects of specific exposures. To the extent that patients with heavy exposures had
longer sick-leave, a protective effect of sick-leave would also tend to obscure any
negative impact of occupational exposures on prognosis.
Staal et al (2008; the Netherlands) (54) conducted a prognostic study based on a
randomised trial that compared two types of open hernia repair (both with mesh)
among patients with a first-time inguinal hernia. From 2004 to 2005, 172 patients
were enrolled in the trial, and 88% (of whom 99% men) were followed for three
months with respect to pain-related disability as measured by the Pain Disability
Index (PDI). The PDI contains seven subscales of activities of daily living and the
index ranges from 0 (best) to 70 (worst). Preoperatively, 41.8% of the patients
assessed their employment as light, 29.5% assessed their employment as heavy, and
the remaining 28.8% were unemployed or retired. Results showed that light work
tended to be associated with a lower PDI preoperatively than heavy work was (12.07
versus 16.65, p= 0.06). The difference was statistically significant when assessed two
weeks after surgery (14.23 versus 20.14, p=0.04). Three months after surgery, the
difference had disappeared (p=0.57). It was not stated, which proportions who had
resumed work at these points in time. Results suggested that pain-related disability
assessed preoperatively and 14 days postoperatively was more pronounced for
patients who rated their work as heavy than for patients who rated their work as light,
but the clinical importance of the difference may be limited; this was not discussed.
Pain lasting for only 14 days may not qualify as persistent pain. The prospective
design was a strength. However, preoperative pain is in general considered a
54
predictor of postoperative pain (30). To the extent that patients with pain
overestimated their exposures at the preoperative assessment, information bias may
be an explanation of the observed differences.
Gender differences
Men have a constitutional predisposition for both medial and lateral inguinal hernia,
cf. the introduction. Only two risk studies provided results specifically for women
(2;12). Self-reported physical work activity was not related to inguinal hernia repair in
one of these studies (12). In the other, rural residency was a risk factor first-time
inguinal hernias among women, but the assumption that rural residence is as a proxy
for high physical activity is weak (2). Results with respect to rural residency were not
reported for men (2). Women are more likely to report prolonged postoperative pain
than men are (22;30). The potential influence of work on postoperative prognosis has
hardly been explored among women.
55
DISCUSSION
We aimed to make a comprehensive literature search, but we may have missed
publications, e.g. in languages other than English. We did not include abstracts and
unpublished results, and we did not contact authors for original data. However, we
feel confident that important high-quality studies were not overlooked by our search
strategy. In order to be able to retrieve the study (40) that was only identified through
a review paper, we revised our search string and succeeded in retrieving the study by
adding the search term “physical activity”. Using the revised search string, we
identified 80 new references, but except for the study that we specifically looked for,
none of them fulfilled our criteria for inclusion in the present review. Publication bias
was hardly a major problem considering the diverse results. The most important
limitation of this review was the poor quality of the reports that we identified
regarding risk and prognosis of inguinal hernia in relation to occupational exposures.
In particular, the estimated physical efforts or physical (work) activities were
indicators of energy expenditure that at the most only indirectly reflected specific
occupational risk factors for inguinal hernia or prognostic factors for inguinal hernia
repair. Please note that the quality assessment is relative to the focus of the review -
some of the reports contained important information with respect to other research
questions.
Risk of inguinal hernia by occupation or occupational mechanical exposures
Indications of an increasing risk with increasing physical effort at work were found in
one small study that was based on independent exposure assessment, but neglected
adjustment for confounders including age (42). Positive associations in three other
studies might well be explained by inflationary bias (38;39;41), and the negative
56
findings for men in the only prospective study might well be explained by exposure
misclassification (2). Two studies reported simple comparisons of cases and controls
with respect to average physical work activity, and the average hardly differed
between groups (11;12).
The only prospective study used self-reported crude estimates of physical activity
during work (2). The remainder of the studies were based on cross-sectional or
retrospective data. The scores used for exposure assessment tended to obscure the
nature of the studied exposures even more than would have been the case if job titles
had been used per se. None of the studies on occupations or occupational exposures
investigated effects of generic occupational exposures such as total daily load lifted,
frequency of lifting loads weighing more than a specified number of kilograms, time
per day spent standing/walking etc.
In general, outcome assessment was unspecific. First-time and recurrent hernias were
often combined so that risk factors and prognostic factors were mixed up. Except for
subanalyses in one study (11), none of the studies analysed lateral and medial hernias
separately, and sometimes femoral hernias and even other abdominal hernias were
included. The lumping together of different hernia types may have masked relations
between exposures and specific outcomes. Among the studies that did not rely on self-
reported outcomes, the majority considered hernia repair. Hernia repair may be
regarded as a proxy for hernia formation, but since asymptomatic hernias may remain
unnoticed, and since asymptomatic and minimally symptomatic hernias may not
require surgery, it is impossible to distinguish between risk factors for hernia
formation and factors that provoke or aggravate symptoms from a pre-existing hernia
57
in studies focussing on hernia repair. Studies that entail clinical examination (cf. (3))
and maybe ultrasonography of men representing contrasting occupational mechanical
exposures could help disentangle these possibilities. However, it may be argued that
the distinction is somewhat academic because the heart of the problem is risk factors
for symptoms and for becoming a patient. When compared to the deficiencies in
exposure and outcome assessment, potential lack of blinding of examiners to exposure
status seemed a minor problem.
In the four included case-control studies (11;12;41;42), cases and controls were
compared with respect to potential confounders, and non-significant differences were
implicitly taken as reassurance that results would not be confounded. This is a fallacy,
however, because a potential confounding factor may still be associated with the
exposure under study in the population that gave rise to the cases. Only two studies
controlled for important potential confounders such as age (2;3).
Risk of inguinal hernia in relation to a single strenuous event
Effects of single strenuous events were merely studied in case series (43-45). The
proportion of hernias that was reported to have a sudden onset varied considerably
from study to study, which maybe reflected the way questions on onset were asked.
Case-crossover designs were not employed although these designs have been
developed to evaluate if anything unusual took place shortly before the sudden onset
of an event/health outcome (59). Admittedly, a case-crossover study of patients with
sudden onset hernias would be an immense challenge, just considering the efforts
needed to identify new cases and contact patients shortly after the onset; hernias may
58
even have been present, but unnoticed by the patient before an event that provoked
symptoms.
Contributory evidence with respect to risk of hernia formation
Injury mechanisms may involve increased intra-abdominal pressure leading to
herniation of the tissues through the inguinal canal or a through a weak point in the
abdominal muscles/aponeuroses (http://www.mayoclinic.com/health/inguinal-
hernia/DS00364/DSECTION=causes) or the transversalis fascia. Increased intra-
abdominal pressure has been hypothesised to be an important stimulus for hernia
formation (60). Significant increases in intra-abdominal pressure have been observed
during a variety of occupational activities. In 20 healthy young people, 10 men and 10
women, measured mean pressures while sitting, standing, and walking up a flight of
stairs were 17 mmHg, 20 mmHg, and 69 mmHg, respectively, while jumping in place
generated the highest pressure of 171 mmHg (61). Intra-abdominal pressure increased
with the speed of walking/running up to a mean of 38 mmHg, and intra-abdominal
pressures above 100 mmHg were often measured in relation to a jump down from a
height of 0.4 m (62). A gradual increase in intra-abdominal pressure has been found
during sustained lifting, reaching levels around 20 mmHg when the subjects were
exhausted after around eight minutes (63). Intra-abdominal pressures above 100
mmHg have been measured during heavy lifting in a stooping position, especially
during rapid lifts (64), and intra-abdominal pressures around 120 mmHg have been
measured during lifting for a few seconds using maximal force (65). Sudden trunk
loading during simulated patient handling situations where the patient fell resulted in
peak intra-abdominal pressures of 153 mmHg among well-trained men and 120
mmHg among well-trained women (66). These findings suggest that specific
59
occupational mechanical exposures may be associated with increased intraabdominal
pressures and that detailed exposure assessment may be needed in future studies of
risk of inguinal hernia in order to reflect this potential injury mechanism.
In childhood, lateral inguinal hernias arise from incomplete obliteration of the
processus vaginalis. In a study based on laparoscopy, a patent processus vaginalis was
found in 30.9% (29/94) of men and in 9.5% (23 /242) of women who were on average
50 years old and had not previously undergone inguinal hernia repair (67). During a
mean follow-up period of 5.5 years, an inguinal hernia was diagnosed in 11.5% of the
patients who had a patent processus vaginalis (at least four of these six hernias were
lateral) and in 3% of the others. The authors concluded that a patent processus
vaginalis was a risk factor for lateral inguinal hernias in adults. Although gender
stratified analyses would be necessary to reach this conclusion because men have an
increased risk of both inguinal hernia and patent processus vaginalis, the study did
illustrate that part of the working age male population may be particularly vulnerable
to exposures that increase intraabdominal pressures or otherwise widen the pre-
existing opening. The observations by Sanjay & Woodward (44) seem to be consistent
with this potential mechanism in that lateral hernias were more likely to have a
sudden onset than medial hernias were and that a sudden onset was more likely
among patients with heavy work. Also in the study by Salcedo-Wasicek & Thirlby
(53) lateral hernias were associated with heavy lifting. Individual vulnerability does
not preclude the work-relatedness of disorders that have a multifactorial aetiology, as
long as occupational exposures contribute to an increased risk.
60
Among 53 male athletes (mainly soccer players, mean age 26) with unclear groin pain
and no palpable hernia, 4 lateral and 8 medial hernias were diagnosed by means of
herniography, i.e. X-ray examination after injection of a contrast medium into the
peritoneal cavity (68). It was noted that the prevalence of medial hernias was
remarkably high, considering the young age of the athletes (68). If corroborated, this
observation could generate the hypothesis that peak forces during sports and work
may traumatise the transversalis fascia and increase the risk of especially medial
herniation. Maybe mechanical exposures can also act through a mechanism involving
gradual degradation and weakening of the transversalis fascia (60;68-70) leading to
accelerated age-induced degeneration, cf. the increasing ratio of medial to lateral
hernias with age (7). In accordance with this, connective tissue alterations have been
reported to be more pronounced in patients with a medial inguinal hernia than in
patients with a lateral inguinal hernia (71). Hernia formation has been related to
increased elasticity of the transversalis fascia (72) and to weak collagen structure
and/or defects in collagen (73-75) and elastic fibre (76) metabolism. However, we are
not aware of any studies that have related mechanical exposures to pathologic
connective tissue alterations in the inguinal region.
Postoperative prognosis by occupation or occupational mechanical exposures
After open repair, one study of older date suggested that medium and heavy work was
associated with an increased risk of recurrence (our calculations) (47), one study,
which was underpowered, also suggested an increased risk of recurrence in relation to
occupational exposures (46), one clearly underpowered study was uninformative (48),
two studies suggested no increase in risk in relation to occupational exposures
(49;50), and one study suggested that early return to work did not increase the risk of
61
recurrence (35). We identified three studies on risk of recurrence after laparoscopic
repair; two of these studies indicated an increased risk of recurrence among patients in
the exposed groups (40;49), whilst the third study did not (50). Across the included
studies on recurrence, convalescence tended to increase with occupational exposure
intensities, which may have had a protective effect. Convalescence has been shortened
considerably since the 1970ies without an increasing trend in risk of recurrence. This
may in part be explained by increasing use of mesh-based instead of conventional
open techniques (77) and in part be related to the fact that the most heavily exposed
patients have not shortened their convalescence to the same degree as less exposed
patients - they still tend to be on sick-leave for 14 days after surgery even when
advised to return to work early (35). Taken together, the studies on postoperative pain
in relation to occupational mechanical exposures did not suggest substantial
associations, but crude exposure assessment may have masked negative effects of
specific exposures, and a protective effect of sick-leave may also have obscured any
negative impact of occupational exposures on prognosis with respect to persistence of
postoperative pain.
Gender differences
Inguinal hernia is primarily a disorder that affects men. The potential influence of
occupational mechanical exposures on risk and prognosis among women has hardly
been studied.
62
Comparison with other reviews of the literature and clinical guidelines
One review found that the literature did not give a clear answer to the question if
physical stresses or events are causally associated with hernias, and did not find any
study focussing on the association between early return to work and risk of hernia
relapse (34). Another review stated that activity level seemed to be both protective
and detrimental depending on the study in focus, but did not provide references to
substantiate the statement (15). A third review concluded that the sparse literature did
not support a relation between herniation and single or recurrent strenuous events and
did not support a relation between early return to work and reoperation (78). The
European Hernia Society has graded the evidence of long-term heavy work as a risk
factor for inguinal hernias to level 3, i.e. based on studies of low quality. Thus, our
conclusions agree quite well with those of the wider literature. According to the
European Hernia Society’s guidelines, heavy weight lifting (probably referring to a
sports activity) should be banned for 2-3 weeks following surgery, whereas other
limitations are not warranted (1). Danish clinical guidelines state that patients can be
active immediately after surgery when this is not hindered by pain (4). However,
prolonged reaction time due to pain has been reported with respect to driving, and this
may be the case for operating other machines as well (79).
Evidence synthesis
On the basis of this review, we find that there is insufficient epidemiologic evidence
(grade 0) to draw meaningful conclusions about the existence of a causal association
between specific occupational mechanical exposures and the development of medial
and lateral inguinal hernia. The limited epidemiologic literature, on the other hand,
does not rule out important associations, and the contributory evidence with respect to
63
intraabdominal pressures, a patent processus vaginalis, and – to a lesser extent -
connective tissue alterations, points to mechanisms that may link mechanical
exposures to inguinal hernia formation.
We also find that there is insufficient epidemiologic evidence (grade 0) to draw
meaningful conclusions about the existence of a prognostic association between
specific occupational mechanical exposures and negative postoperative outcomes in
terms of hernia recurrence and persistent pain. There is no evidence supporting
prolonged convalescence in order to avoid recurrence and persistent postoperative
pain, but on the other hand, it remains to be shown that patients with high
occupational mechanical exposures can safely return to work immediately after
surgery.
Research needs
There is a need for high-quality studies of occupational risk factors for lateral and
medial inguinal hernia formation in order to corroborate or exclude causal relations.
The Danish Hernia Database distinguishes between medial and lateral hernias, which
the Danish National Patient Register does not. In collaboration with a researcher from
the Danish Hernia Database, three of the authors of this reference document are
currently conducting a nationwide male cohort study focussing on quantitative
exposure-response relations. Exposure assessment is based on individual job histories
according to the Employment Classification Module in Statistics Denmark (80)
combined with a Job exposure matrix based on occupational physicians’ quantitative
assessments of generic mechanical exposures (81). The plan is to continue this line of
research using data from the Musculoskeletal Research Database at the Danish
64
Ramazzini Centre, which will allow us to take important potential confounders into
account. Maybe inguinal hernias occur at a younger age in highly exposed jobs, and it
would be interesting to explore this hypothesis of risk acceleration (82;83). The
influence of occupational exposures on reoperation rates and prolonged postoperative
pain warrants further study.
CONCLUDING REMARKS
Inguinal hernia is a common disorder, especially among men, and inguinal hernia
repair is one of the most common operations in general surgery. Based on this review,
we find that there is insufficient epidemiologic evidence (grade 0) to draw meaningful
conclusions about the existence of a causal association between specific occupational
mechanical exposures and the development of medial and lateral inguinal hernia.
However, contributory evidence points to mechanisms that may link mechanical
exposures to inguinal hernia formation. We also find that there is insufficient
epidemiologic evidence (grade 0) to draw meaningful conclusions about the existence
of a prognostic association between specific occupational mechanical exposures and
outcomes after inguinal hernia repair. The limited epidemiologic literature does not
rule out important associations. This review revealed several research needs in order
to determine if the disorder can be prevented and if the postoperative prognosis can be
improved by reducing occupational mechanical exposures.
65
ACKNOWLEDGEMENTS
We are grateful to the reviewers Morten Bay-Nielsen, Danish Hernia Database,
Department of Surgical Gastroenterology, H:S Hvidovre, University Hospital,
Denmark, Nils Fallentin, Center for Physical Ergonomics, Liberty Mutual Research
Institute for Safety, Hopkinton, Massachusetts, US, and Sigurd Mikkelsen,
Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark.
The Danish Working Environment Research Fund funded the study (grant no
20110038393/4).
66
APPENDIX 1 Grading of evidence
Framework for assessing the evidence of a causal association between an exposure to
a specific risk factor and a specific outcome according to the Scientific Committee of
the Danish Society of Occupational and Environmental Medicine.
For assessing the evidence of a prognostic association, we used an adjusted version of
this framework, where we replaced the word “causal” with the word “prognostic”.
With a view to potential prevention, we were interested in causal associations between
risk factors and negative prognostic outcomes, rather than prediction per se (36;37).
Strong evidence of a causal association (+++): A causal relationship is very likely. A
positive relationship between exposure to the risk factor and the outcome has been
observed in several epidemiological studies. It can be ruled out with reasonable
confidence that this relationship is explained by chance, bias, or confounding.
Moderate evidence of a causal association (++): A causal relationship is likely. A
observed in several epidemiological studies. It cannot be ruled out with reasonable
confidence that this relationship can be explained by chance, bias, or confounding,
although this is not a very likely explanation.
Limited evidence of a causal association(+): A causal relationship is possible. A
observed in several epidemiological studies. It is not unlikely that this relationship can
be explained by chance, bias, or confounding.
67
Insufficient evidence of a causal association (0): The available studies are of
insufficient quality, consistency, or statistical power to permit a conclusion regarding
the presence or absence of a causal association.
Evidence suggesting lack of a causal association (-): Several studies of sufficient
quality, consistency and statistical power indicate that the specific risk factor is not
causally related to the specific outcome.
Comments
The classification does not include a category for which a causal relation is considered
as established beyond any doubt. The key criterion is the epidemiological evidence.
The likelihood that chance, bias, and confounding may explain observed associations
is a criterion that encompasses criteria such as consistency and number of “high
quality” studies.
Biological plausibility and contributory information may add to the evidence of a
causal association.
68
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Hernia, Occupational Exposure

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Risk and prognosis of inguinal hernia in relation to occupational mechanical

exposures – a systematic review of the epidemiologic evidence

Hospital West Jutland

UDVIDET DANSK RESUME (EXTENDED DANISH SUMMARY) ...................3

Literature search .................................................................................................................................14

Risk of inguinal hernia by occupation or occupational mechanical exposures...................................19

Risk of inguinal hernia by occupation or occupational mechanical exposures...................................56

CONCLUDING REMARKS ....................................................................................65

APPENDIX 1 Grading of evidence ..........................................................................67

Objective To evaluate the epidemiologic evidence for a causal effect of occupational

mechanical exposures on incidence of inguinal hernia, and for a prognostic effect of

Methods We performed a literature search in Medline, Embase and Web of Science

until November 3 2011 to identify peer-reviewed papers on risk of inguinal hernia or

prognosis after inguinal hernia repair in relation to occupation or occupational

mechanical exposures. We also included studies on risk of inguinal hernia in relation

and strengths and limitations were discussed.

factors. Eight studies provided information on risk by occupation or occupational

exposure and/or outcome assessment. Three studies focussed on single strenuous

bias, confounding and inadequate reporting of results.

Conclusion There is insufficient epidemiologic evidence (grade 0) to draw

meaningful conclusions about the existence of causal associations between specific

rule out important associations.

Occupational exposure, inguinal hernia, risk, prognosis

Baggrund for problemstillingen

Denne gennemgang blev lavet i henhold til Arbejdsmiljøforskningsfondens opslag i

december 2010 vedrørende udredninger om erhvervssygdomme, tema 2:

Sammenhænge mellem lyskebrok (hernia inguinalis medialis et lateralis) og fysiske

lyskekanalen) og det mediale eller direkte (gennem bugvæggen). Lyskekanalen er

skråt forløbende gennem bugens muskulatur og lukkes normalt af en slags klap-

mekanisme. Et medfødt lyskebrok hos drenge er altid et lateralt lyskebrok. Det

laterale. I nogle tilfældene findes medialt og lateralt lyskebrok samtidigt, hvilket

Lyskebrok optræder hyppigst hos mænd med en aldersjusteret hyppighed på 7-8

gange i forhold til kvinder.

risikofaktorer for lyskebrok, og enkeltstående fysiske anstrengelser har været

mistænkt for at kunne føre til en pludselig udvikling af et lyskebrok. Sygefravær og

operation og forventede fysiske anstrengelser i arbejdet.

holdepunkterne for eventuelle årsagssammenhænge mellem udvikling af medialt og

lateralt lyskebrok og udsættelse for forskellige mekaniske påvirkninger i arbejdet.

Endvidere var det formålet at undersøge mekaniske påvirkningers betydning for

brokket og langvarige smerter. Hensigten var at fokusere på arbejde med store

samlede daglige løftemængder, gentagne tunge enkeltløft, personforflytninger og

skub/træk samt langvarigt stående/gående arbejde. Udredningen skulle desuden

omfatte en vurdering af kønnets eventuelle betydning.

Udredningens resultater er samlet i et referencedokument i henhold til retningslinjer

udarbejdet af Arbejdsmiljøforskningsfonden. Udredningen bygger på en gennemgang

af den epidemiologiske litteratur om sammenhænge mellem arbejdsrelaterede

påvirkninger og udvikling af lyskebrok. Hvert studie er gennemgået systematisk, og

er gennemgået for mulige fejlkilder og ensartethed af resultaterne på tværs af de

forskellige studier. Udredningen indeholder herudover afsnit om konkurrerende

konklusion i henhold til Arbejdsmiljøforskningsfondens kriterier.

Der blev gennemført en litteratursøgning efter videnskabelige artikler i tre

computeriserede databaser: Medline, Embase og Web of Science. Ved søgningen blev

der brugt søgeord relateret til lyskebrok og erhvervseksponeringer (mekaniske

påvirkninger, tunge løft, stående/gående arbejde). Artiklerne skulle være forfattet på

fagfællebedømmelse. Alle artikler, som blev identificeret ved søgningen, gennemgik

en tretrins screeningsproces: 1) Artiklernes titler blev gennemgået for at finde

læst for at fravælge de undersøgelser, der ikke var relevante, og 3) de resterende

to forskere uafhængigt af hinanden. Den endelige udvælgelse skete efter konsensus i

dermed indgik 23 artikler i referencedokumentet. Sammenhængen mellem

erhvervsmæssige mekaniske belastninger og risikoen for lyskebrok blev belyst i otte

artikler omhandlede prognosen efter operation for lyskebrok.

Af de otte studier af sammenhængen mellem erhvervsmæssige mekaniske

belastninger og udvikling af lyskebrok var tre tværsnitsundersøgelser, fire var case-